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SAN JOAQUIN�UNTY ENVIRONMENTAL HEALT�PARTMENT <br /> SERVICE REQUEST <br /> Typ f Busines r Property FACILITY ID# SERVICE REQUEST# <br /> M <br /> Owtl�pv <br /> / <br /> V,,IU/�' CHECK If BILLING ADDRESS <br /> FACILfrY NAME © 61v4m <br /> *00q3-) <br /> SIIE ADDREs �2 1 vd (37d <br /> Street Number DirectionqZ0 Street Name mvq Zi Code <br /> HOME or M LING ADDRESS (if Different from Site Address) ` <br /> / <br /> DG�7 <br /> Street Number Street Name <br /> CITY S � ZIP UOOZ3 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( 1) $ <br /> PHONE#2 E.T. BOS DISTRICT LOCATION CODE <br /> ( ) -T-A-07 b 3 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 0 �, t �� ' <br /> GUS CHECK If BILLING ADDRESSEY <br /> BUSINESS NAME PHONE If 44 / 65• 1 EXT. <br /> HOME Or MAILING KEr1DRESS y,� ' ,/ (�_#_n +0 , <br /> CITY ! , �'/ flJ►V( STATE ` ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ( x" DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT �V <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: S TT, � (� P pr-QEIVED <br /> COMMENTS: FEB 2 5 2 <br /> SAN JOAOUIN COUNT <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: CQ�� t �[� EMPLOYEE#: ©j z,f DATE: p <br /> ASSIGNED TO: h l EMPLOYEE#: -7 <br /> 3 `� DATE: ZS U <br /> Date Service Completed (if already completed): SERVICE CODE: /Q P/E: oZ3 -Ce <br /> Fee Amount: •pv Amount Paid f Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003- <br />